The panel suggested that pharmacotherapeutic agents should be selected to treat primary disorders and aggressive symptoms. They favor monotherapy, when possible, to facilitate assessment of treatment regimen effectiveness and side effects and to enhance adherence to the regimen. The panel conceded, however, that monotherapy may not always be sufficient.
"Clinical experience indicates that the severity and frequency of aggressive symptoms often necessitate the simultaneous use of antipsychotic medications along with first-line treatments for the primary conditions" (Pappadopulos et al., 2003).
The panel preferred atypical antipsychotics to typical antipsychotics because of their safer acute side-effect profiles, in spite of weight gain and endocrinologic side effects associated with atypical agents. The panel maintained that these do not negate the advantages of the atypicals acute use.
"However, the choice of a particular atypical antipsychotic medication should be made based on patient/ guardian acceptability, comorbid general medical conditions, prior individualized drug response, side effect profile, and long-term treatment planning" (Pappadopulos et al., 2003).
The panel recommended a conservative dosing strategy of "start low, go slow, taper slow." They noted evidence of youth responding to lower antipsychotic doses than adults but possibly not before two weeks of treatment. The panel cautioned that patients should be monitored for signs of withdrawal dyskinesia during the period of gradual dose tapering before discontinuation.
For acute and emergency treatment of aggression, the panel recommended psychosocial crisis management before medication. It urged facility staff to develop a range of intervention options to prevent or reduce likelihood of escalating aggression.
"Psychosocial interventions to help patients regain self-control during this period can help avoid the need for chemical and physical restraints" (Pappadopulos et al., 2003).
The use of stat or as-needed medications should be minimized, according to the panel. If these are frequently necessary, the panel suggested imposing dose and frequency ceilings or, preferably, supplanting them with optimized dosages on a fixed schedule.